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APPLICATION FOR SANITATION PERMIT Permit No. [Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance wit County 0 inan No 549. JOB ADDRESS AND LOCATION---- --- -- t Owner's Name_ ------------------- Phone-------�-�------------ Address---------- .�Y ----------------------------- Contractor's Name- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel, ❑ Othe I / --�---------------------- Number of living units: __-/___ umber of bedrooms __C_- Number of baths .__:!_. Lot size ____[.2 Wafer Supply: Public system [Community system 'El Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ""/HardpanE]PP Previous Application Made: Yes ❑ No E2" New Construction: Yes [/No El TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1� Septic ank: Distance from nearest well___________-Distan q fro fount on_______I Q_ .Mateli�i__ __ ____ _____ ____--- No. of compartments------------�--------Size_/r-_�-� ---Liquid depth--------/L��--------------Capacity Dispos Field: Distance from nearest well___. .fl__- Distance from {oundation_________ __._.Distance to nearest lot line Q_� Width of trench__________ 1__ __ f Number of lines___ -- -- gyp-Length of each line______________ Off----- t ------ Type of filter mater . ______- __ epth of filter ,material______. __ g --Total length �-a.0- ----------------- Seepage Pit:T Distance to nearest well__________--________Distance from foundation---------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material--------------- Size: Diameter------------------------ Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid ---- -------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- --to nearest lot line--------------------------- ! ----------------------------- # -- El Remodeling and/or repairing (descnb }._ �� ------- ------------- -----------------------------------------------------------------•--------------------------------- --------------------------------------------------------- ----- -- ----- H- ----------------------- ----••--------------------------------------•------------------------- - ------------------------------- I hereby certify that I have pre0ared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f = ----------- ------------------------------- (Owner and/or Contractor) [Signed)----- ---------------- ---- ------------------------------------------- ----------------------- By�----------•--- •--------•--- --------- r -----(Title)---------------------------------------------------------------- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �I FOR DEPARTMENT USE ONLY r–,� APPLICATIONACCEPTED B - -------------------------------------------------- --------------------------------------- DATE!~---------------------------------------------------- , REVIEWED BY-------------------------- -- ----- DATE- r�–----------------------------------------- ------ BUILDING PERMIT ISSUED------------ DATE e------------------------------------------------- Alterations and/or recommendations---------------------- --------------------------------------------------------------------- ---------------- -- ----------------- ----------------------1- --•-------•- -• - --------------• --------- -------- --- ----------- ------//14v----00h e'l-'i---------?'aw -------- ------- Ir S f!l�ri- r -----•- ---------- -----------------------------------^� /---------4f....... ly--..--------------------E:cyP��', ,�7�5: �� ,�----- � �- ------------------------- ° ------ ------ / � a� � -------------------------- L/ �j7/!?2t /� Date . FINAL INSPECTION BY-- -------------- ------------- ----- --�-� ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak 5+tee{ 132 Sycamore 5+teat 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California k _ ES-9-2M B-51 Pevisod W-2100